Tennessee tackles tobacco: A population-based tobacco cessation initiative

Background: Cigarette smoking is the single greatest contributor to preventable morbidity and mortality in the United States (U.S.), yet effective strategies to promote smoking cessation are frequently not available to medically vulnerable populations. Baseline surveys completed in 2007 indicated 37% (Healthy People 2010 goal is 12%) of patients reporting for care in Tennessee's public health clinics were current cigarette smokers, 40% indicated a provider had discussed their tobacco use in the previous year, and more than half wanted to quit. The Tennessee Department of Health aimed to implement and evaluate a standardized, population-based, tobacco cessation intervention based on the Transtheoretical Model for Change (5 A's) targeting a reduction in the percentage of patients who smoke. Methods: A core multidisciplinary team (medicine, nursing, pharmacy, clerical, administration) developed standard tobacco cessation protocols for each discipline, and 2,400 public health workers completed standardized training during the fall of 2007. A tobacco cessation checklist was developed, and team member responsibilities were defined: a) clerks screen all patients for tobacco use, b) public health nurses (PHNs) provide cessation counseling, dispense over the counter cessation aids via protocol, initiate Tennessee Quitline coaching referrals, and screen and refer candidates for prescription cessation aids to physicians or advanced practice nurses. Pre-implementation pilots were conducted in one large, suburban, health department with a primary care clinic and one small (1-RN) rural public health clinic without primary care capacity. Evaluation measures include the percentage of patients screened, referred, and treated for tobacco dependence; patient demographics and tobacco-related behaviors; and successful and unsuccessful quit attempts. Statewide program implementation began in mid-November, 2007. Results: Twelve weeks post-implementation, more than 100,000 patients (about 60% of patients reporting for care) have been screened for tobacco use, more than 8,000 patients have received pharmaceutical cessation aids, and Quitline referrals have increased significantly. Conclusions: Preliminary findings suggest population-based tobacco cessation support for medically vulnerable patients can be standardized and improved using the 5-As, and PHN's can effectively direct and manage delivery of the majority of these services via protocol.